Meeting Site Application Form - Greater Insurance Service,

Need help? Call: 1-888-636-7174

Home | Products | Resources | About Us | Contact Us

MEETING SITE APPLICATION

We hereby enroll for group membership in RecoverSource and apply for the Premises Liability Insurance coverage. Please mail a check or money order, made payable to:
RECOVERSOURCE • PO BOX 309 • GRAND RAPIDS, MN 55744

If you would like to print this form (PDF) and mail it to us, please click here.
You can call us at 1-800-851-4291

ALL FIELDS MUST BE FILLED IN

Name:

Name of Group:

Address of Meeting Site:
(Designated Premises)*

City:

State:

ZIP:

*If group meets at more than one location, each site must be listed in order to be covered. Please include a sheet that lists all locations, including building owners and their address.

Estimated Number of Members in Group:

How Often Group Meets: Meets once a week Other (specify)

CONTACT PERSON:
Name:
Telephone:
Email:

MAILING ADDRESS FOR GROUP: (If different from meeting site address)
Name:
Address:
City:
State:
ZIP:

BUILDING OWNER:
Building Owners Name:
Address:
City:
State:
ZIP:

Additional comments::